Health Check Name* First Last Birthdate* Date Format: MM slash DD slash YYYY Do you have a fever or have felt hot or feverish anytime in the last two weeks?*YesNoDo you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?*YesNoHave you experienced a recent loss of smell or taste?*YesNoHave you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?*YesNoHave you returned from travel outside of Canada in the last 14 days?*YesNoHave you returned from travel within Canada from a location known affected with COVID-19?*YesNoIs your workplace considered high risk?*YesNoDo you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder,COPD, any chance of pregnancy?*YesNoIf you have answered YES to any of the questions above please call our office directly. NameThis field is for validation purposes and should be left unchanged.